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Vitamin and mineral requirements in human nutrition
Second edition

WHO Library Cataloguing-in-Publication Data Joint FAO/WHO Expert Consultation on Human Vitamin and Mineral Requirements (1998 : Bangkok, Thailand). Vitamin and mineral requirements in human nutrition : report of a joint FAO/WHO expert consultation, Bangkok, Thailand, 21–30 September 1998. 1.Vitamins — standards 2.Micronutrients — standards 3.Trace elements — standards 4.Deficiency diseases — diet therapy 5.Nutritional requirements I.Title. ISBN 92 4 154612 3 (LC/NLM Classification: QU 145)

© World Health Organization and Food and Agriculture Organization of the United Nations 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications — whether for sale or for noncommercial distribution — should be addressed to Publications, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int), or to Chief, Publishing and Multimedia Service, Information Division, Food and Agriculture Organization of the United Nations, 00100 Rome, Italy. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization and the Food and Agriculture Organization of the United Nations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization and the Food and Agriculture Organization of the United Nations in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization and the Food and Agriculture Organization of the United Nations do not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Designed by minimum graphics Typeset by SNP Best-set Typesetter Ltd., Hong Kong Printed in China by Sun Fung

Contents
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Foreword Acknowledgements 1. Concepts, definitions and approaches used to define nutritional needs and recommendations 1.1 Introduction 1.2 Definition of terms 1.2.1 Estimated average requirement 1.2.2 Recommended nutrient intake 1.2.3 Apparently healthy 1.2.4 Protective nutrient intake 1.2.5 Upper tolerable nutrient intake level 1.2.6 Nutrient excess 1.2.7 Use of nutrient intake recommendations in population assessment 1.3 Approaches used in estimating nutrient intakes for optimal health 1.3.1 The clinical approach 1.3.2 Nutrient balance 1.3.3 Functional responses 1.3.4 Optimal intake 1.4 Conclusions References 2. Vitamin A 2.1 Role of vitamin A in human metabolic processes 2.1.1 Overview of vitamin A metabolism 2.1.2 Biochemical mechanisms for vitamin A functions 2.2 Populations at risk for, and consequences of, vitamin A deficiency 2.2.1 Definition of vitamin A deficiency 2.2.2 Geographic distribution and magnitude 2.2.3 Age and sex iii

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2.2.4 Risk factors 2.2.5 Morbidity and mortality 2.3 Units of expression 2.4 Sources and supply patterns of vitamin A 2.4.1 Dietary sources 2.4.2 Dietary intake and patterns 2.4.3 World and regional supply and patterns 2.5 Indicators of vitamin A deficiency 2.5.1 Clinical indicators of vitamin A deficiency 2.5.2 Subclinical indicators of vitamin A deficiency 2.6 Evidence used for making recommendations 2.6.1 Infants and children 2.6.2 Adults 2.6.3 Pregnant women 2.6.4 Lactating women 2.6.5 Elderly 2.7 Recommendations for vitamin A requirements 2.8 Toxicity 2.9 Recommendations for future research References 3. Vitamin D 3.1 Role of vitamin D in human metabolic processes 3.1.1 Overview of vitamin D metabolism 3.1.2 Calcium homeostasis 3.2 Populations at risk for vitamin D deficiency 3.2.1 Infants 3.2.2 Adolescents 3.2.3 Elderly 3.2.4 Pregnant and lactating women 3.3 Evidence used for estimating recommended intakes 3.3.1 Lack of accuracy in estimating dietary intake and skin synthesis 3.3.2 Use of plasma 25-OH-D as a measure of vitamin D status 3.4 Recommended intakes for vitamin D 3.5 Toxicity 3.6 Recommendations for future research References 4. Calcium 4.1 Introduction 4.2 Chemistry and distribution of calcium iv

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4.3 4.4

Biological role of calcium Determinants of calcium balance 4.4.1 Calcium intake 4.4.2 Calcium absorption 4.4.3 Urinary calcium 4.4.4 Insensible losses 4.5 Criteria for assessing calcium requirements and recommended nutrient intakes 4.5.1 Methodology 4.5.2 Populations at risk for calcium deficiency 4.6 Recommendations for calcium requirements 4.6.1 Infants 4.6.2 Children 4.6.3 Adolescents 4.6.4 Adults 4.6.5 Menopausal women 4.6.6 Ageing adults 4.6.7 Pregnant women 4.6.8 Lactating women 4.7 Upper limits 4.8 Comparisons with other recommendations 4.9 Ethnic and environmental variations in the prevalence of osteoporosis 4.9.1 Ethnicity 4.9.2 Geography 4.9.3 Culture and diet 4.9.4 The calcium paradox 4.10 Nutritional factors affecting calcium requirement 4.10.1 Sodium 4.10.2 Protein 4.10.3 Vitamin D 4.10.4 Implications 4.11 Conclusions 4.12 Recommendations for future research References 5. Vitamin E 5.1 Role of vitamin E in human metabolic processes 5.2 Populations at risk for vitamin E deficiency 5.3 Dietary sources and possible limitations to vitamin E supply 5.4 Evidence used for estimating recommended intakes 5.5 Toxicity v

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5.6 Recommendations for future research References 6. Vitamin K 6.1 Introduction 6.2 Biological role of vitamin K 6.3 Overview of vitamin K metabolism 6.3.1 Absorption and transport 6.3.2 Tissue stores and distribution 6.3.3 Bioactivity 6.3.4 Excretion 6.4 Populations at risk for vitamin K deficiency 6.4.1 Vitamin K deficiency bleeding in infants 6.4.2 Vitamin K prophylaxis in infants 6.4.3 Vitamin K deficiency in adults 6.5 Sources of vitamin K 6.5.1 Dietary sources 6.5.2 Bioavailability of vitamin K from foods 6.5.3 Importance of intestinal bacterial synthesis as a source of vitamin K 6.6 Information relevant to the derivation of recommended vitamin K intakes 6.6.1 Assessment of vitamin K status 6.6.2 Dietary intakes in infants and their adequacy 6.6.3 Factors of relevance to classical vitamin K deficiency bleeding 6.6.4 Factors of relevance to late vitamin K deficiency bleeding 6.6.5 Dietary intakes in older infants, children, and adults and their adequacy 6.7 Recommendations for vitamin K intakes 6.7.1 Infants 0–6 months 6.7.2 Infants (7–12 months), children, and adults 6.8 Toxicity 6.9 Recommendations for future research References 7. Vitamin C 7.1 Introduction 7.2 Role of vitamin C in human metabolic processes 7.2.1 Background biochemistry 7.2.2 Enzymatic functions vi

103 104 108 108 108 110 110 111 112 112 113 113 114 115 115 115 116 117 117 117 118 119 120 120 122 122 125 126 126 126 130 130 130 130 130

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7.2.3 Miscellaneous functions Consequences of vitamin C deficiency Populations at risk for vitamin C deficiency Dietary sources of vitamin C and limitations to vitamin C supply 7.6 Evidence used to derive recommended intakes of vitamin C 7.6.1 Adults 7.6.2 Pregnant and lactating women 7.6.3 Children 7.6.4 Elderly 7.6.5 Smokers 7.7 Recommended nutrient intakes for vitamin C 7.8 Toxicity 7.9 Recommendations for future research References 7.3 7.4 7.5 8. Dietary antioxidants 8.1 Nutrients with an antioxidant role 8.2 The need for biological antioxidants 8.3 Pro-oxidant activity of biological antioxidants 8.4 Nutrients associated with endogenous antioxidant mechanisms 8.5 Nutrients with radical-quenching properties 8.5.1 Vitamin E 8.5.2 Vitamin C 8.5.3 b-Carotene and other carotenoids 8.6 A requirement for antioxidant nutrients 8.7 Recommendations for future research References 9. Thiamine, riboflavin, niacin, vitamin B6, pantothenic acid, and biotin 9.1 Introduction 9.2 Thiamine 9.2.1 Background 9.2.2 Biochemical indicators 9.2.3 Factors affecting requirements 9.2.4 Evidence used to derive recommended intakes 9.2.5 Recommended nutrient intakes for thiamine 9.3 Riboflavin 9.3.1 Background 9.3.2 Biochemical indicators 9.3.3 Factors affecting requirements vii

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9.3.4 Evidence used to derive recommended intakes 9.3.5 Recommended nutrient intakes for riboflavin 9.4 Niacin 9.4.1 Background 9.4.2 Biochemical indicators 9.4.3 Factors affecting requirements 9.4.4 Evidence used to derive recommended intakes 9.4.5 Recommended nutrient intakes for niacin 9.5 Vitamin B6 9.5.1 Background 9.5.2 Biochemical indicators 9.5.3 Factors affecting requirements 9.5.4 Evidence used to derive recommended intakes 9.5.5 Recommended nutrient intakes for vitamin B6 9.6 Pantothenate 9.6.1 Background 9.6.2 Biochemical indicators 9.6.3 Factors affecting requirements 9.6.4 Evidence used to derive recommended intakes 9.6.5 Recommended nutrient intakes for pantothenic acid 9.7 Biotin 9.7.1 Background 9.7.2 Biochemical indicators 9.7.3 Evidence used to derive recommended intakes 9.7.4 Recommended nutrient intakes for biotin 9.8 General considerations for B-complex vitamins 9.8.1 Notes on suggested recommendations 9.8.2 Dietary sources of B-complex vitamins 9.9 Recommendations for future research References 10. Selenium 10.1 Role of selenium in human metabolic processes 10.2 Selenium deficiency 10.2.1 Non-endemic deficiencies of selenium 10.2.2 Keshan disease 10.2.3 Kaschin-Beck disease 10.2.4 Selenium status and susceptibility to infection 10.2.5 Selenium and thyroid hormones 10.3 The influence of diet on selenium status 10.4 Absorption and bioavailability 10.5 Criteria for assessing selenium requirements viii

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10.6

Recommended selenium intakes 10.6.1 Adults 10.6.2 Infants 10.6.3 Pregnant and lactating women 10.7 Upper limits 10.8 Comparison with other estimates 10.9 Recommendations for future research References 11. Magnesium 11.1 Tissue distribution and biological role of magnesium 11.2 Populations at risk for, and consequences of, magnesium deficiency 11.3 Dietary sources, absorption, and excretion of magnesium 11.4 Criteria for assessing magnesium requirements and allowances 11.5 Recommended intakes for magnesium 11.6 Upper limits 11.7 Comparison with other estimates 11.8 Recommendations for future research References 12. Zinc 12.1 12.2 12.3 12.4 12.5

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Role of zinc in human metabolic processes Zinc metabolism and homeostasis Dietary sources and bioavailability of zinc Populations at risk for zinc deficiency Evidence used to estimate zinc requirements 12.5.1 Infants, children, and adolescents 12.5.2 Pregnant women 12.5.3 Lactating women 12.5.4 Elderly 12.6 Interindividual variations in zinc requirements and recommended nutrient intakes 12.7 Upper limits 12.8 Adequacy of zinc intakes in relation to requirement estimates 12.9 Recommendations for future research References

13. Iron 13.1 Role of iron in human metabolic processes 13.2 Iron metabolism and absorption 13.2.1 Basal iron losses 13.2.2 Requirements for growth ix

VITAMIN AND MINERAL REQUIREMENTS IN HUMAN NUTRITION

13.2.3 Menstrual iron losses 13.2.4 Iron absorption 13.2.5 Inhibition of iron absorption 13.2.6 Enhancement of iron absorption 13.2.7 Iron absorption from meals 13.2.8 Iron absorption from the whole diet 13.2.9 Iron balance and regulation of iron absorption 13.3 Iron deficiency 13.3.1 Populations at risk for iron deficiency 13.3.2 Indicators of iron deficiency 13.3.3 Causes of iron deficiency 13.3.4 Prevalence of iron deficiency 13.3.5 Effects of iron deficiency 13.4 Iron requirements during pregnancy and lactation 13.5 Iron supplementation and fortification 13.6 Evidence used for estimating recommended nutrient intakes 13.7 Recommendations for iron intakes 13.8 Recommendations for future research References 14. Vitamin B12 14.1 Role of vitamin B12 in human metabolic processes 14.2 Dietary sources and availability 14.3 Absorption 14.4 Populations at risk for, and consequences of, vitamin B12 deficiency 14.4.1 Vegetarians 14.4.2 Pernicious anaemia 14.4.3 Atrophic gastritis 14.5 Vitamin B12 interaction with folate or folic acid 14.6 Criteria for assessing vitamin B12 status 14.7 Recommendations for vitamin B12 intakes 14.7.1 Infants 14.7.2 Children 14.7.3 Adults 14.7.4 Pregnant women 14.7.5 Lactating women 14.8 Upper limits 14.9 Recommendations for future research References 15. Folate and folic acid 15.1 Role of folate and folic acid in human metabolic processes x

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15.2 15.3 15.4 15.5

Populations at risk for folate deficiency Dietary sources of folate Recommended nutrient intakes for folate Differences in bioavailability of folic acid and food folate: implications for the recommended intakes 15.6 Considerations in viewing recommended intakes for folate 15.6.1 Neural tube defects 15.6.2 Cardiovascular disease 15.6.3 Colorectal cancer 15.7 Upper limits 15.8 Recommendations for future research References 16. Iodine 16.1 Role of iodine in human metabolic processes 16.2 Populations at risk for iodine deficiency 16.3 Dietary sources of iodine 16.4 Recommended intakes for iodine 16.4.1 Infants 16.4.2 Children 16.4.3 Adults 16.4.4 Pregnant women 16.5 Upper limits 16.5.1 Iodine intake in areas of moderate iodine deficiency 16.5.2 Iodine intake in areas of iodine sufficiency 16.5.3 Excess iodine intake References 17. Food as a source of nutrients 17.1 Importance of defining food-based recommendations 17.2 Dietary diversification when consuming cereal- and tuber-based diets 17.2.1 Vitamin A 17.2.2 Vitamin C 17.2.3 Folate 17.2.4 Iron and zinc 17.3 How to accomplish dietary diversity in practice 17.4 Practices which will enhance the success of food-based approaches 17.5 Delineating the role of supplementation and food fortification for micronutrients which cannot be supplied by food 17.5.1 Fortification xi

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17.5.2 Supplementation 17.6 Food-based dietary guidelines 17.7 Recommendations for the future 17.8 Future research needs References Annex 1: Recommended nutrient intakes – minerals Annex 2: Recommended nutrient intakes – water- and fat-soluble vitamins

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Foreword

In the past 20 years, micronutrients have assumed great public health importance. As a consequence, considerable research has been carried out to better understand their physiological role and the health consequences of micronutrient-deficient diets, to establish criteria for defining the degree of public health severity of micronutrient malnutrition, and to develop prevention and control strategies. One of the main outcomes of this process is greatly improved knowledge of human micronutrient requirements, which is a crucial step in understanding the public health significance of micronutrient malnutrition and identifying the most appropriate measures to prevent them. This process also led to successive expert consultations and publications organized jointly by the Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO) and the International Atomic Energy Agency (IAEA) providing up-to-date knowledge and defining standards for micronutrient requirements in 19731, 19882 and in 19963. In recognition of this rapidly developing field, and the substantial new advances that have been made since the most recent publication in 1996, FAO and WHO considered it appropriate to convene a new expert consultation to re-evaluate the role of micronutrients in human health and nutrition. To this end, background papers on the major vitamins, minerals and trace elements were commissioned and reviewed at a Joint FAO/WHO Expert Consultation (Bangkok, 21–30 September 1998). That Expert Consultation was assigned three main tasks: • Firstly, the Consultation was asked to review the full range of vitamin and mineral requirements—19 micronutrients in all—including their role in
1

2

3

Trace elements in human nutrition. Report of a WHO Expert Committee. Geneva, World Health Organization, 1973 (WHO Technical Report Series, No. 532). Requirements of vitamin A, iron, folate and vitamin B12. Report of a Joint FAO/WHO Expert Consultation. Rome, Food and Agriculture Organization of the United Nations, 1988 (FAO Food and Nutrition Series, No. 23). Trace elements in human nutrition and health. Geneva, World Health Organization, 1996.

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normal human physiology and metabolism, and conditions of deficiency. This included focusing on and revising the requirements for essential vitamins and minerals, including vitamins A, C, D, E, and K; the B vitamins; calcium; iron; magnesium; zinc; selenium; and iodine, based on the available scientific evidence. • Secondly, the Consultation was asked to prepare a report that would include recommended nutrient intakes for vitamins A, C, D, E, and K; the B vitamins; calcium; iron; magnesium; zinc; selenium; and iodine. The report should provide practical advice and recommendations which will constitute an authoritative source of information to all those from Member States who work in the areas of nutrition, agriculture, food production and distribution, and health promotion. • Thirdly, the Consultation was asked to identify key issues for future research concerning each vitamin and mineral under review and to make preliminary recommendations on that research. The present report presents the outcome of the Consultation combined with up-to-date evidence that has since become available to answer a number of issues which remained unclear or controversial at the time of the Consultation. It was not originally thought that such an evidence-based consultation process would be so controversial, but the reality is that there are surprisingly few data on specific health status indicators on which to base conclusions, whereas there is a great deal of information relative to overt deficiency disease conditions. The defining of human nutrient requirements and recommended intakes are therefore largely based on expert interpretation and consensus on the best available scientific information. When looking at recommended nutrient intakes (RNIs) in industrialized countries over the last 25 years, it is noticeable that for some micronutrients these have gradually increased. The question is whether this is the result of better scientific knowledge and understanding of the biochemical role of the nutrients, or whether the criteria for setting requirement levels have changed, or a combination of both. The scientific knowledge base has vastly expanded, but it appears that more rigorous criteria for defining recommended levels is also a key factor. RNIs for vitamins and minerals were initially established on the understanding that they are meant to meet the basic nutritional needs of over 97% of the population. However, a fundamental criterion in industrialized countries has become one of the presumptive role that these nutrients play in “preventing” an increasing range of disease conditions that characterize affected populations. The latter approach implies trying to define the notion of
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FOREWORD

“optimal nutrition”, and this has been one of the factors nudging defined requirements to still higher levels. This shift in the goal for setting RNIs is not without reason. The populations that are targeted for prevention through “optimal nutrition” are characterized by sedentary lifestyles and longer life expectancy. The populations in industrialized countries are ageing, and concern for the health of the older person has grown accordingly. In contrast, the micronutrient needs of population groups in developing countries are still viewed in terms of millions experiencing deficiency, and are then more appropriately defined as those that will satisfy basic nutritional needs of physically active younger populations. Nevertheless, one also needs to bear in mind the double burden of under- and overnutrition, which is growing rapidly in many developing countries. Concern has been raised about possible differences in micronutrient needs of populations with different lifestyles for a very practical reason. The logic behind the establishment of micronutrient needs of industrialized nations has come about at the same time as a large and growing demand for a wide variety of supplements and fortificants, and manufacturers have responded quickly to meet this market. This phenomenon could easily skew national strategies for nutritional development, with an increased tendency to seek to resolve the micronutrient deficiency problems of developing countries by promoting supplements and fortification strategies, rather than through increasing the consumption of adequate and varied diets. Higher levels of RNIs often set in developed countries can easily be supported because they can be met with supplementation in addition to food which itself is often fortified. In contrast, it often becomes difficult to meet some of the micronutrient needs in some populations of developing countries by consuming locally available food, because foods are often seasonal, and neither supplementation nor fortification reach vulnerable population groups. Among the nutrients of greatest concern is calcium; the RNI may be difficult to meet in the absence of dairy products. The recently revised United States/Canada dietary reference intakes (DRIs) propose only an acceptable intake (AI) for calcium instead of a recommended daily allowance (RDA) in recognition of the fact that intake data are out of step with the relatively high intake requirements observed with experimentally derived values.1 Another nutrient of concern is iron, particularly during pregnancy, where supplementation appears to be essential during the second half of pregnancy.

1

Food and Nutrition Board. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC. National Academy Press. 1997.

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Folic acid requirements are doubled for women of childbearing age to prevent the incidence of neural tube defects in the fetus. Conversion factors for carotenoids are under review, with the pending conclusion that servings of green leafy vegetables needed to meet vitamin A requirements probably need to be at least doubled. In view of this uncertainty, only “recommended safe intakes” rather than RNIs are provided for this vitamin. Selenium is the subject of growing interest because of its properties as an antioxidant. The RNIs recommended herein for this micronutrient are generally lower than those derived by the United States Food and Nutrition Board because the latter are calculated on a cellular basis, whereas the present report relies on more traditional whole-body estimates.1 Are these “developments” or “new understandings” appropriate for and applicable in developing countries? The scientific evidence for answering this question is still emerging, but the time may be near when RNIs may need to be defined differently, taking into account the perspective of developing countries based on developing country data. There may be a need to identify some biomarkers that are specific to conditions in each developing country. There is therefore a continuing urgent need for research to be carried out in developing countries about their specific nutrient needs. The current situation also implies that the RNIs for the micronutrients of concern discussed above will need to be re-evaluated as soon as significant additional data are available. Kraisid Tontisirin Director Division of Food and Nutrition Food and Agriculture Organization of the United Nations Graeme Clugston Director Department of Nutrition for Health and Development World Health Organization

1

Food and Nutrition Board. Dietary reference intakes for vitamin C, vitamin E, selenium and carotenoids. A report of the Panel on Dietary Antioxidants and Related Compounds. Washington, DC, National Academy Press, 2000.

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Acknowledgements

We wish to thank the authors of the background papers: Leif Hallberg, Department of Clinical Nutrition, Göteborg University, Annedalsklinikerna, Sahlgrenska University Hospital, Göteborg, Sweden; Glenville Jones, Department of Biochemistry—Medicine, Queen’s University, Kingston, Ontario, Canada; Madhu Karmarkar, Senior Adviser, International Council for Control of Iodine Deficiency Disorders, New Delhi, India; Mark Levine, National Institute of Diabetes & Digestive & Kidney Diseases, National Institute of Health, Bethesda, MD, USA; Donald McCormick, Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA; Colin Mills, Director, Postgraduate Studies, Rowett Research Institute, Bucksburn, Scotland; Christopher Nordin, Institute of Medical and Veterinary Sciences, Clinical Biochemistry Division, Adelaide, Australia; Maria Theresa Oyarzum, Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile; Chandrakant Pandav, Regional Coordinator, South-Asia and Pacific International Council for Control of Iodine Deficiency Disorders; and Additional Professor, Center for Community Medicine, All India Institute of Medical Sciences, New Delhi, India; Brittmarie Sandström,1 Research Department of Human Nutrition, The Royal Veterinary and Agricultural University, Frederiksberg, Denmark; John Scott, Department of Biochemistry, Trinity College, Dublin, Ireland; Martin Shearer, Vitamin K Research Unit of the Haemophilia Centre, The Rayne Institute, St Thomas’s Hospital, London, England; Ajay Sood, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India; David Thurnham, Howard Professor of Human Nutrition, School of Biomedical Sciences, Northern Ireland Centre for Diet and Health, University of Ulster, Londonderry, Northern Ireland; Maret Traber, Linus Pauling Institute, Department of Nutrition and Food Management, Oregon State University, Corvallis, OR, USA; Ricardo Uauy, Director, Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago,
1

Deceased.

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VITAMIN AND MINERAL REQUIREMENTS IN HUMAN NUTRITION

Chile; Barbara Underwood, formerly Scholar-in-Residence, Food and Nutrition Board, Institute of Medicine, National Academy of Sciences, Washington, DC, USA; and Cees Vermeer, Faculteit der Geneeskunde Biochemie, Department of Biochemistry, University of Maastricht, Maastricht, Netherlands. A special acknowledgement is made to the following individuals for their valuable contributions to, and useful comments on, the background documents: Christopher Bates, Medical Research Council, Human Nutrition Research, Cambridge, England; Robert E. Black, Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA; James Blanchard, Pharmaceutical Sciences, Department of Pharmacology and Toxicology, University of Arizona, Tucson, AZ, USA; Thomas Bothwell, Faculty of Medicine, University of the Witwatersrand, Witwatersrand, South Africa; Chen Chunming, Senior Adviser, Chinese Academy of Preventive Medicine, Beijing, China; William Cohn, F. Hoffman-La Roche Ltd, Division of Vitamins, Research and Technology Development, Basel, Switzerland; François Delange, International Council for Control of Iodine Deficieny Disorders, Brussels, Belgium; C. Gopalan, President, Nutrition Foundation of India, New Delhi, India; Robert P. Heaney, Creighton University Medical Center, Omaha, NE, USA; Basil Hetzel, Children’s Health Development Foundation, Women’s and Children’s Hospital, North Adelaide, Australia; Glenville Jones, Department of Biochemistry—Medicine, Queen’s University, Kingston, Ontario, Canada; Walter Mertz,1 Rockville, MD, USA; Ruth Oniang’o, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya; Robert Parker, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; Robert Russell, Professor of Medicine and Nutrition and Associate Director, Human Nutrition Research Center on Aging, Tufts University, United States Department of Agriculture Agricultural Research Service, Boston, MA, USA; Tatsuo Suda, Department of Biochemistry, Showa University School of Dentistry, Tokyo, Japan; John Suttie, Department of Biochemistry, University of Wisconsin-Madison, Madison, WI, USA; Henk van den Berg, TNO Nutrition and Food Research Institute, Zeist, Netherlands; Keith West Jr., Johns Hopkins School of Hygiene and Public Health, Division of Human Nutrition, Baltimore, MD, USA; and Parvin Zandi, Head, Department of Food Science and Technology, National Nutrition & Food Technology Research Institute, Tehran, Islamic Republic of Iran.

1

Deceased.

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ACKNOWLEDGEMENTS

Acknowledgements are also made to the members of the Secretariat: Ratko Buzina, formerly Programme of Nutrition, WHO, Geneva, Switzerland; Joan Marie Conway, Consultant, FAO, Rome, Italy; Richard Dawson, Consultant, Food and Nutrition Division, FAO, Rome, Italy; Sultana Khanum, Programme of Nutrition, WHO, Geneva, Switzerland; John R. Lupien, formerly Director, Food and Nutrition Division, FAO, Rome, Italy; Blab Nandi, Senior Food and Nutrition Officer, FAO Regional Office for Asia and the Pacific, Bangkok, Thailand; Joanna Peden, Public Health Nutrition Unit, London School of Hygiene and Tropical Medicine, London, England; and Zeina Sifri, Consultant, Food and Nutrition Division, FAO, Rome, Italy. Finally, we express our special appreciation to Guy Nantel who coordinated the FAO edition of the report, and to Bruno de Benoist who was responsible for the WHO edition in close collaboration with Maria Andersson. We also wish to thank Kai Lashley and Ann Morgan for their assistance in editing the document and Anna Wolter for her secretarial support.

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